Overcoming Barriers to Opioid Treatment Takes Center Stage

Presidential Commission, Annals of Family Medicine Study Call for Greater Access to MAT

On July 31, the U.S. Commission on Combating Drug Addiction and the Opioid Crisis submitted its interim report(www.whitehouse.gov) to President Donald Trump, asking him to declare the opioid epidemic in the United States a national emergency. The commission contended that such a declaration would empower the president's cabinet to act and spur Congress to fund efforts to turn the tide.

"With approximately 142 Americans dying every day, America is enduring a death toll equal to Sept. 11 every three weeks," the commission said in its report, which just this week sparked the administration's attention.

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On July 31, the U.S. Commission on Combating Drug Addiction and the Opioid Crisis submitted its interim report to President Donald Trump.

Among the report's numerous recommendations is a call to fund a federal incentive program to increase the availability of medication-assisted treatment to combat opioid use disorder.

This recommendation comes just as a recent study in Annals of Family Medicine found that about 60 percent of rural counties in the United States don't have a single physician with a DEA waiver to prescribe buprenorphine.

Improving Access to Medication-assisted Treatment

Among numerous recommendations included in the report is a call to fund a federal incentive program to improve access to medication-assisted treatment (MAT) for opioid use disorder (OUD), including through expanding the number of clinicians nationwide who possess a DEA waiver to prescribe buprenorphine.

This need is aptly illustrated in a study(www.annfammed.org) published in the July/August issue of Annals of Family Medicine that found about 60 percent of rural counties in the United States (where much of the epidemic is located) don't have a single physician who has a DEA waiver to prescribe buprenorphine.

To make matters worse, study co-author Holly Andrilla, M.S., biostatistician and research scientist for the University of Washington's WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) Rural Health Research Center in Seattle, told AAFP News this startling statistic actually understates the problem. For the study, Andrilla and her co-authors surveyed all rural physicians the DEA listed as having received a waiver to prescribe buprenorphine as of April 2016.

What they found, she said, was that "more than half of physicians with the initial (DEA) waiver are not actually treating patients." There are several reasons for this, Andrilla continued, including the fact that providing MAT is difficult and time-consuming.

"Numerous physicians reported that they didn't have the space or staff, or clinical management told them they couldn't provide MAT," she said, adding that the amount of complexity often involved in managing these patients (e.g., need for subspecialty backup or psychosocial support services) can also discourage physicians from providing MAT.

Eliminating Barriers to Treatment

The most common barriers to prescribing buprenorphine for OUD among physicians included in the study were concerns about diversion, lack of available mental health support services and time constraints, said Andrilla. The good news is that numerous innovative approaches being tested in rural areas across the country attempt to address the limitations in availability of mental health support services, as well as time constraints among clinicians, she noted.

"Using telehealth portals in hospitals or other established health facilities to provide counseling to rural patients is one such idea," Andrilla said. "This addresses the difficulty of attracting providers to small rural places and the stigma so often associated with getting help for opioid use disorder. In small towns, this also helps protect confidentiality."

In addition, Andrilla noted, the Comprehensive Addiction and Recovery Act(www.congress.gov) enacted in July 2016 allows nurse practitioners and physician assistants to obtain a waiver to prescribe buprenorphine. "This may allow some practices to address the time constraint issue by having these providers actively manage buprenorphine patients," she said.

From the patient perspective, aside from stigma and confidentiality concerns, barriers among patients in rural areas who seek treatment for OUD include the time and monetary expense required to travel long distances for treatment, said Andrilla.

Furthermore, such barriers to using MAT are amplified in incarcerated populations with OUDs, the commission noted in its report, because despite multiple studies that showed individuals with OUDs who received MAT during and after incarceration had lower mortality risk, remained in treatment longer, and had fewer drug screens and lower rates of recidivism than their peers who did not, there is "often inadequate access to FDA-approved medications that are proven to improve outcomes as part of a full continuum of care."

Additional Commission Recommendations

The commission included a wide-ranging assortment of other recommendations for fighting the opioid epidemic in its report to the president, including the following:

Grant waiver approvals for all 50 states to quickly eliminate treatment barriers resulting from the so-called Institute for Mental Diseases exclusion within Medicaid, which prohibits federal Medicaid funds from being used to reimburse services provided in inpatient facilities with more than 16 beds that treat "mental diseases," including substance use disorders (SUDs).

Provide model legislation for states to allow dispensing of the overdose-reversing medication naloxone via standing orders, as well as requiring the co-prescribing of naloxone along with high-risk opioid medications. The commission also recommended equipping all law enforcement officers with naloxone.

Provide federal funding and technical support to states to enhance data-sharing among state-based prescription drug monitoring programs.

Better align patient privacy laws focused on addiction with the Health Insurance Portability and Accountability Act to ensure information pertaining to SUDs is available to medical professionals who treat and prescribe medications to patients.

Use a standardized parity compliance tool to enforce the Mental Health Parity and Addiction Equity Act so that health plans cannot impose less favorable benefits for mental and substance use diagnoses than for physical health diagnoses.

AAFP Stance on Educational Mandates

It's worth noting that the commission report also called for mandatory medical education in opioid prescribing and risks of developing an SUD for medical and dental students, as well as prescriber training for practicing clinicians by amending the Controlled Substance Act to require all DEA registrants "to take a course in proper treatment of pain."

AAFP policy, however, has for years stipulated that the Academy "opposes legislation or executive action that would require mandatory education of family physicians as a condition for prescribing specific drugs, such as opioids."

The AAFP most recently expressed that view in a July 10 letter to the FDA(3 page PDF), which stated that although the Academy recognizes the need for evidence‐based physician education to ensure safe and effective use of extended-release and long-acting opioids as well as short-acting opioids, "we maintain that mandating CME for individual prescribers is not the solution for this public health crisis.

"Therefore, we oppose policies that would require mandatory education of family physicians as a condition for prescribing opioids."